Received date: August 07, 2013; Accepted date: September 18, 2013; Published date: September 24, 2013

Citation: O’Reilly-Landry M (2013) The Drive to Relate: How Modern Psychoanalysis can Join with Modern Medicine to Improve the Doctor-Patient Relationship. J Psychol Psychother 3:126. doi:10.4172/2161-0487.1000126

Abstract

Advanced medical science and technology have made extraordinary contributions to health and longevity, but have simultaneously precipitated a psychological crisis for many recipients of medical care. Medical patients often express disappointment in the care they receive; they may feel dehumanized and that their doctor does not know or care about them. In addition, the medical literature is replete with discussions of the difficult problem of patients’ lack of adherence to medical regimen. While the power of modern medicine to heal and save lives has never been greater, patients are not always satisfied with the doctor-patient relationship or cooperative with the care that is offered to them. Relational and Interpersonal psychoanalysts believe that there exists an innate need to emotionally attach to caregivers, and that this need is even more fundamental than Freud’s concept of the need to gratify basic drives. Modern psychoanalysis emphasizes the importance to mental health of attention to the subjective and relational dimensions of life. Psychoanalytic research has demonstrated that being emotionally attended to, treated as subject, not merely an object, for example, has calming and healing properties. The present paper describes contemporary psychoanalytic concepts that can be utilized to better understand and address the medical patient’s experience and behavior within the context of modern medicine. Drawing on theory and research, recommendations are made for improving the psychological dimension of modern medicine through attention to the subjective experience of both medical patients and clinicians.

Keywords

Introduction

Modern medicine has made extraordinary contributions to health
and longevity. People live longer and healthier lives and derive great
benefit from the vast improvements in medical science and technology.
But this advance in medical care has precipitated a psychological crisis
for many of its recipients. Along with gratitude for a life saved or
health restored, patients often express disappointment in the care they
receive--they feel dehumanized and may complain that their doctor
does not know, or does not care, about them. Unexpectedly, at a time
when the power of modern medicine to heal and save lives has never
been greater, patients are dissatisfied and disappointed with the doctorpatient
relationship.

Illness, especially a serious one, brings with it fear and a sense of
vulnerability and isolation for the patient [1,2]. As such times, people
need more from their doctor than an accurate diagnosis. They need
to feel their doctor knows who they are and is thinking about them.
This assures them that their doctor is trying his or her best to solve
their problem and to come up with the best treatment possible. But the
psychological need to be thought about goes even deeper. Especially
at these moments, the patient experiences a fundamental need to feel
acknowledged, understood and held in mind.

In an earlier era, the physician would have visited the patient at
home and known him in the context of his family, for whom he also
would have cared. For the modern patient, scans by machines and
consultations with multiple specialists often substitute for the oldfashioned
comprehensive physical examination, a ritual in which the
patient has psychological as well as physical contact with the physician.
Verghese [3] laments the diminishing of this direct contact with the
patient and warns that the practice of modern medicine is creating the
“iPatient,” a phantom composite of scan and test results that substitute
for the human being. The person of the doctor has become disengaged from the person of the patient. Modern patients now are struggling to
retain their subjectivity and sense of wholeness in the age of biomedical
science, technology and subspecialization. Through technology, the
human body is seen with penetrating clarity, but the human being is
left hidden in the shadows. The field of medicine is making enormous
strides in its quest to master the body; but it is losing its grip on the
patient as a whole person and as a being in relation to others.

The fields of psychosomatic medicine, medical psychology, health
psychology and consultation-liaison psychiatry have for many years
studied ways to improve the quality of life for people with medical
illnesses. And oncology is a subspecialty that has been particularly active
in attempting to address the psychological dimension of serious medical
illness. Gilewski from the American Society of Clinical Oncology, for
example, recently stated two key concepts consistent with the present
paper: 1. emphasis on science and technology often overshadows the
humanistic aspects of medicine and 2. The doctor-patient relationship
is of one of mutual influence and consists of reciprocal interactions [4].
All of these efforts to enhance the psychological and social dimensions
of care within the biopsychosocial model have been fruitful, but they
have lacked a theoretical framework with which to organize their
thinking. Modern psychoanalytic theory has the breadth, depth
and scope of interest to provide a highly useful and practical way to
understand the psychological dimension of modern medicine as it is
currently practiced.

The present paper proposes that modern psychoanalytic theory,
with its multi-dimensional view of subjectivity and human relationships,
provides a unified and useful conceptual framework for understanding
the psychosocial aspects of modern medicine. This paper discusses
ways in which particular psychoanalytic ideas can elucidate the medical
patient’s experience, illness behavior and interactions with the modern
medical system. From the vantage point of this in-depth, humanistic
perspective on the highly technological field of modern medicine, ways
to improve the quality of medical care are suggested.

The Psychological Trauma of Modern Medicine

Being the recipient of medical care involves confronting issues of
life and death, as well as threats to bodily integrity and psychological
wholeness. Modern medicine saves lives, but may result in living a
compromised existence, frequently with continued dependence on and
interaction with, the medical profession. The achievements of traditional
medicine are invariably accomplished by bodily impingement and
invasion, at times gentle and pleasant, as with medication that relieves
painful symptoms, at other times aggressive, as when a surgeon excises
a tumor. The practices of modern medicine disrupt personal physical
boundaries to an even more dramatic degree. Machines can peer inside
the body without entering, while others physically penetrate the body in
order to explore or manipulate what is there. Doctors move organs and
other essential parts from one body to another through transfusions
and organ transplantations. In the case of surrogate mothers, a woman
can use her whole body to carry, grow and give birth to an infant that is
the genetic offspring of people she may never have met. Technology also
enables modern medicine to make use of non-human replacements for
human organs and other body parts, thus blurring the boundary, not
only between self and other, but between the human and the inanimate.

New kinds of relationships are fostered between a physically
incomplete human being and an external replacement device. O’Reilly-
Landry [5] has elsewhere written about the emotional complexities
of being physically and psychologically connected to a life-sustaining
device such as a dialysis machine, including the internal fantasies that
can be stimulated in the mind of the patient in such anxiety-laden,
potentially traumatic situations. Although not part of the physical
human body, replacement organs and devices certainly become
incorporated into the mind of the person who is medically ill. Through
symbolization, a mechanical device can come to represent, sometimes
unconsciously, aspects of the inner psychological self. The following
case of Mr. Q demonstrates how medical objects can take on emotional
significance at an unconscious level.

Mr. Q.

Following a diagnosis of laryngeal cancer, Mr Q underwent surgery
to remove his larynx. Now rendered unable to create speech sounds, Mr
Q was presented with an electro-larynx, a hand-held, battery-operated
device that substitute for a larynx by transforming air vibrations into
mechanical-sounding speech. Initially resistant to using the device.
Finally accepting that his was the only way he could communicate
effectively with others, he overcame his initial inhibitions about using
it in public. It soon became his constant companion. Years later, Mr. Q
consulted a psychologist to help him deal with his feelings about his
failing health. At one point, he was dissatisfied with an aspect of the
medical treatment he was getting, but kept this to himself, as he was
a very polite man who wanted to be respectful of his doctors. He was
afraid his doctor would be upset if he complained.

One day, Mr. Q came to his psychotherapy appointment only to realize he had left his electro-larynx at home. This came as a surprise
to both Mr. Q and his psychologist, since Mr. Q never went anywhere
without the device on which he so heavily relied for interacting with the
world. Since talk therapy was not possible in the absence of his ability to
speak, they both decided it did not make sense to meet, and Mr. Q went
back home. For the next appointment, Mr. Q arrived with his electrolarynx.
Since this was unusual behavior for him, it seemed possible
that there was some unspoken, possibly unconscious reason for leaving
it at home, and that perhaps this was not just a simple act of forgetting.
The therapist recalled that the session prior to the forgetting had been
a very emotional one for Mr. Q, as he had expressed a great deal of
anguish and grief about what seemed to him at the time to be a very
bleak situation. Wondering whether there might be a link between Mr.
Q forgetting his electro-larynx and what had happened in the previous
session, the therapist asked Mr. Q how he had felt about their earlier
meeting just prior to the forgetting of his mechanical device. Just as he
had difficulty criticizing his physician, so was it difficult for Mr. Q to
acknowledge any critical feelings about the therapist. He did, however,
admit to feeling disappointed that she had not been more supportive
when he had clearly been in so much emotional pain. The psychologist
recalled that in a much earlier session, Mr. Q had thanked her for
providing him with the space to be able to feel and express his feelings
without being intruded upon. Keeping this in mind, the psychologist
had tried to create the same safe space for Mr. Q by giving him plenty
of emotional room to express his feelings. She deliberately pulled
back and remained fairly quiet while he expressed some deeply felt
emotional pain. Unfortunately, this had not been what Mr. Q wanted at
that particular moment. Together, Mr. Q and his therapist put together
an understanding that Mr. Q’s forgetting of his “voice box” was not
accidental; it had been unconsciously motivated to prevent him from
“speaking up” and expressing the criticism and anger he was attempting
to avoid acknowledging. Mr. Q appeared to be defending against
his anger by rendering himself incapable of expressing it verbally,
thereby protecting the therapist from the potential psychological
harm he imagined it would cause her. Attending to Mr. Q’s emotional
experience, particularly those aspects he felt were unacceptable, opened
up a dialogue about the respectful, but ultimately self-defeating, way he
had been relating to the therapist and to other doctors: he managed to
preserve the relationship, but at expense to himself, since his failure to
speak up directly with his medical doctors and with his psychologist
prevented him from getting what he needed from each of them. This
understanding was enabled by the conversation with Mr. Q regarding
the way he psychologically made use of the device that represented to
him the ability to put his feelings into words.

The Central Importance of Relationships to Treatment
Outcome

Psychotherapy research has demonstrated reliably that the quality
of the relationship between therapist and patient is a powerful factor in
determining the outcome of the treatment [6]. This is not to say that the
therapeutic relationship is the only thing that matters in determining
psychotherapeutic outcomes. It does suggest, however, that the
therapeutic value of a psychological treatment is diminished in the
absence of a trusting and cooperative engagement with the therapist.
Perhaps the same can be said of the relationship between medical doctor
and patient: that the effectiveness of a medical treatment is greatest when
the patient is positively engaged with the doctor and the medical system.
The absence of such a positive emotional connection may contribute
to a patient’s lack of adherence to treatment recommendations [7] or
failure to appear for followup care [8], common problems in the world
of modern medicine.

Comfort and security are compelling factors in forming emotional
attachments and in establishing psychological well-being. Studies of
early maternal deprivation in monkeys famously demonstrated the
importance of the early relationship between mother and baby to the
subsequent social and emotional development of the monkey [9]. In
one classic experiment, Harlow found that baby monkeys who had
been separated from their mothers from birth preferred to spend time
with a wire “mother” covered with soft terry cloth, rather than one that
dispensed milk, and when distressed, ran to the terry cloth mother
[10]. The wire mother who provided only milk can perhaps be seen
as analogous to the doctor who tends only to the medical condition of
the patient, ignoring the ever-important need for emotional and social
contact. A better therapeutic relationship appears to be what medical
patients are requesting when they complain that their doctor does not
know them and does not spend enough time with them.

The Role of Psychoanalysis in Treating Medically Ill
Patients

Psychoanalysis is not merely a psychotherapeutic modality. It is also
a theoretical perspective whose aim is to understand the psychological
complexity of the human mind. With its attention to processes that
occur outside of awareness and beneath the surface, a psychoanalytic
perspective can be particularly helpful in addressing behavior that
might otherwise be regarded as perplexing or enigmatic. Medical or
health psychologists [11] and consultation-liaison psychiatrists are
frequently called on to help when medical patients have difficulty
adjusting to their illness or injury, or when they do not follow the
prescribed medical regimen or engage in adequate self-care. Modern
medicine poses a variety of problems for patients and medical caregivers
that are relational in nature, and psychoanalytic ideas have for many
years been applied to the treatment and management of the medically
ill patient. Psychoanalytically-oriented psychiatrists have long played
an important role in the management of the medical patient through
their consultations in the setting of the general hospital [12,13]. Stein,
for example, described unconscious phenomena as they occur within
the scope of primary care specialties, emphasizing the importance
to the medical clinician of paying attention to one’s own subjective
experience in the counter-transference [14]. Concepts derived from
psychoanalytic theory, such as psychological defense mechanisms,
transference and counter-transference, personality dynamics, and other
clinical insights based on an understanding of the multiple layers of the
mind, can enable mental health clinicians to understand what appears
to medical clinicians to be merely irrational or impossible-to-manage
behavior.

A Potential Role for Modern Psychoanalysis in the
Practice of Modern Medicine

Psychoanalysis, at its origins, explored the multi-dimensional
inner reality of the single individual. It addressed the types of inner
experiences common to all: repression of thoughts and feelings we find
unacceptable, internal conflict, and the tension between expression and
inhibition of feelings and drives [15]. Freud knew that there are levels
of experience that unconscious processes influence overt behavior,
and that behavior and symptoms can have symbolic meaning that
goes beneath the surface [16]. But for Freud and his earlier followers,
psychoanalysis was a one-person psychology, concerned primarily
with the psyche of the single individual. Transference, the feelings the
patient has about the analyst that are rooted in past experiences with
parents, was regarded as solely a manifestation of the patient’s inner
experience, having little to do with the reality of the analyst as a person [17]. Counter-transference, the analyst’s response to the patient’s
transference, was considered to be a nuisance best avoided [18].

As modern medicine withdraws from concern about emotion,
subjective experience and relationships, modern psychoanalysis is
tugging firmly in the opposite direction. It has been over a century since
Freud developed his seminal constructs based on the idea that each
human being struggles to tame our innate biological drives in order to
be properly socialized [15]. In the latter part of the 20th and into the
21st centuries, psychoanalytic theory saw a shift from Freud’s emphasis
on an individual’s defenses against sexual and aggressive drives, to an
emphasis on relationships and emotional involvement with others.
Relational and Interpersonal psychoanalysts emphasize that what is
innate to human beings is a need to form relationships and that this
need is even more fundamental than is internal conflict about the need
to gratify basic drives [19].

During the second half of the twentieth century, psychoanalysis
began to expand its scope and moved toward becoming a two-person
psychology [20]. It began taking into account what goes on overtly and
beneath the surface between two different people. The analyst became
more than a mere blank screen upon which to project the contents of
one’s mind. A more contemporary view is that the therapist also has
his or her own transference to the patient, and the analyst’s countertransference
is considered a useful source of information about the
patient and about the impact of the patient on others. Psychoanalysis
has become a theory of intersubjectivity and mutual influence, [21,22]
rendering it quite suitable for understanding the relational experience
of the whole person embedded in the interpersonal process of the
medical world, in addition to the psychological trauma wrought by the
individual’s experience of threats to body and life.

Useful Contemporary Psychoanalytic Concepts Secure Base

Psychoanalyst Bowlby [23-25] extended Harlow’s ideas about
early maternal-child relationship to human beings. He demonstrated
the great importance to human psychological development of having
a secure early attachment to the mother or to another consistently
available care giving figure. He found that a child requires a “secure
base,” a relationship with another person who provides consistency,
availability and relief from distress. From this secure base, the child
feels free to explore the world, confident in the belief that he or she is
not alone, even in the face of experiences of separateness. Gerretsen
and Myers discuss the importance to the medical patient of the secure
base, in terms of the perceived availability of the physician [26]. They
analyze a case in which a terminally ill man with cancer goes from a
state of anxiety to one of calm when the doctor assures the patient that
he would be potentially available to him 24 hours a day during the
weekend, so that the patient would not be alone with his pain. These
authors suggest to doctors in similar crisis circumstances that they
make explicit their availability in order to counter the patients’ more
standard assumption that their doctor, a significant attachment figure
and source of soothing and comfort, is disconnected from them and
their suffering.

Attachment Security and Anxiety

By far, the most extensive body of psychoanalytic research on
medical patients and illness behavior is in the area of attachment
security, a term first used by psychoanalyst Ainsworth and colleagues
to describe young children’s reactions to brief separation from their
mothers [27]. Clinical researchers have found that the degree of security
or anxiety that patients experience in their close, intimate relationships determines a great deal of what goes on in the medical setting. Medical
patients with a high level of attachment anxiety are less likely to adhere
to medical regimen [7] or present for follow up care [8]. Attachment
security is at times able to predict medical outcome, including the
glucose levels in diabetic patients [28-30] and physical illness such as
auto Hunter and Maunder have looked at the impact of attachment
security and style on how patients interact with medical clinicians and
the medical system [31]. It would undoubtedly be helpful to medical
clinicians to be able to recognize the attachment styles of their patients
and the type of feelings and responses these typically engender on the
part of the health clinician [32].

Mentalization

The attachment relationship gives rise developmentally to the
capacity to recognize and reflect on internal states of mind [33]. Such
reflective functioning, or mentalization, is the ability to conceive of the
self and other as subjective beings. It is the ability to be psychologicallyminded
- to understand internal psychological experiences such as
thoughts, feelings, motivations, desires and conflicts. Mentalization is
an imaginative ability that involves the capacity to hold in mind, the
mind of another. Mentalization-based therapies are effective treatments
for a number of psychological disorders [34-36]. The tendency to
mentalize and consider the subjective state of the patient (and clinician)
is easily lost when the focus is on failing bodies and efforts to sustain life,
and yet nowhere is attention to subjective experience more important
for psychological well-being than in the context of modern medicine.
Kraemer et al. [37] have described the difficulty in the stressful, actionoriented
neo-natal intensive care unit, of maintaining the reflective
functioning required addressing the great emotional needs of parents
and staff as they deal with the anxiety and grief endemic to this setting.
Malberg and Fonagy [38] have written about their experiences applying
a Mentalization-based group intervention to help adolescent patients
with end-stage renal disease cope with the great emotional disruption
of having a serious, life-threatening illness and being dependent on
chronic dialysis for survival.

Patient and Medical Clinician as Subjective Beings

The approach suggested in this paper is to conceive of both patient
and clinician in subjective terms. To focus on the patient’s experience
is quite consistent with Miller and Rollnick’s [39] Motivational
Interviewing technique, an evidence-based approach to helping
patients to change their behavior. In Motivational Interviewing, found
to be effective with medical patients and those who misuse substances,
the clinician focuses on the patient’s subjective experience, which is
often one of ambivalence about making the desired changes. While
offering help and encouraging positive change, the clinician, rather
than insisting on any particular behavior, accepts that it is ultimately up
to the patient whether or not to follow the doctor’s recommendations
or engage in any behavioral change. In both Motiviational Interviewing
and Psychoanalysis, the patient’s subjectivity is acknowledged and
respected; the clinician helps the patient come to terms with mixed
and conflicting feelings and to decide what he or she wants to do.
Another approach that advocates eliciting the subjective view of the
patient is Charon’s Narrative Medicine, in which the physician goes
beyond the usual review of systems, listens closely, and responds to a
patient’s personal story behind the illness. This is an intersubjective
experience in which the physician seeks to “recognize, absorb, interpret
and be moved by the stories of illness.” [40]. Meza and Passerman
[41] address the challenging issue of combining evidence-based with
narrative medicine. Maunder and Hunter describe “an interpersonal dance” between patient and medical caregiver, in which the patient’s
insecure attachment behavior elicits particular types of responses from
others, and ultimately affects the type of medical care he or she receives
[32]. Both Charon and Maunder and Hunter, place the patient into
the context of an inter-subjective, two-person psychology espoused by
modern relationally-oriented psychoanalysis.

Zerbo, Cohen, et al. describe a model for consultation-liaison
psychiatrists to utilize in the general hospital setting when encountering
patients with personality disorders [42]. Though intended for mental
health specialists, much can be learned that can be utilized by the nonmental
health clinician. Individuals with personality problems present
particularly difficult challenges for medical staff in that they may be
dissatisfied with their care or caregivers and can be generally difficult
to get along with; they prove particularly vexing, however, in their
capacity to arouse uncomfortable feelings in those around them. Based
on Transference-Focused Psychotherapy (TFP), an evidence-based,
manualized psychodynamic treatment for people with personality
disorders [43], Zerbo et al. [42] model makes use of those very
unpleasant feelings that these patients induce in the clinician. This model
understands these counter-transferential experiences as reflections of
the feelings the patient disowns because they are too painful for him
or her to tolerate. In general, terms, the intervention centers on the
clinician mentalizing the uncooperative patient; the clinician recognizes,
empathizes with, puts into words, and reflects back, the patient’s own
emotions and subjective experience. Knowledge of TFP and of the
psychological dynamics common to people with different personality
styles helps the consulting mental health clinician to use transference
and counter transference to better understand and empathize with the
patient’s underlying, unarticulated distress. A common result is that the
patient feels acknowledged and understood, and frequently becomes a
bit calmer and more cooperative. Although this form of treatment was
designed for use in long-term outpatient psychotherapy, the model and
framework were found to be applicable to the acute medical setting,
even when no prior relationship existed between doctor and patient. In
a similar vein, psychiatric hospitalist Skomorowski describes varieties
of antisocial behavior and personalities as they present in the general
hospital setting, and the need to understand their differing dynamics
and subjective experiences in the context of the many stresses of being
a hospitalized medical patient [44].

Lev-Ran et al. [45] present a case in which a prescribing psychiatrist,
by attending to his own emotional reactions to a belligerent and nonadherent
patient, and taking responsibility for his contribution to the
negative interaction, was able to form the beginnings of a working
alliance with the patient. This clinician avoided a power struggle of the
type that frequently ensues with uncooperative patients, by attending
to the patient’s subjective experience, rather than the aggressive, noncompliant
behavior itself: “I am hearing what you’re saying about the
medication and the treatment you’re frustrated, you want to feel better,
and you don’t feel that this treatment is helping you yet...You thought
that taking the medications would make a difference and were hoping
it would happen immediately, and now that it hasn’t happened that way
you’re not sure you are going to continue taking them. Have I got that
right?”

Clearly, physicians, nurses and other medical professionals also
feel the stresses brought about by negative interpersonal interactions
that occur in the course of their work. The medical relationship is an
intersubjective one, in which there is mutual influence of two people’s
psyches on one another. Of course, the doctor is there to meet the
needs of the patient, but the physician or the nurse is no less a person or a participant in the medical encounter than is the patient [46].
Medical clinicians can feel great joy when they are successful and their
ministrations result in recovery, but they may despair when they fail,
even when it is not their fault. And being human, they may make errors
that sometimes lead to a bad outcome for a patient. As human beings,
they utilize psychological defense mechanisms to cope with anxiety,
frustration and hopelessness, the sense of loss when a patient dies or
does poorly, or a sense of disappointment in themselves. They may
also fear the anger and grief of their patients or patient’s next-of-kin.
Nissen-Lie et al. [47] found that the private personal life of the therapist
affects the therapeutic relationship, and other medical clinicians should
be open to the possibility that they may unconsciously communicate
aspects of themselves to their patients as well. As the following example
demonstrates, one’s role as physician, nurse or other medical provider
may also influenced by one’s personal life and history:

Dr. C.

Dr. C grew up with a father who was very ill throughout much of her
childhood. Seeing the way the doctors took care of her father made her
want to become one herself. Throughout her medical training and as a
practicing physician, she worked hard and developed a reputation as a
very careful, thoughtful and skilled doctor, dedicated to the health and
well-being of her patients. But this doctor had very poor relationships
with many of her patients. Although they knew she cared about their
medical condition and about getting them better, she behaved harshly
toward them if she felt they were not taking good care of themselves or
were not following her recommendations perfectly. Her patients often
ended up feeling she thought they were unworthy of the high quality
medical care she was providing for them. Some of her patients left her
practice because of the bad feelings she caused for them, and many who
stayed would lie to her about how they were doing because they didn’t
want to risk making her angry. Like everyone, this skilled, dedicated
doctor had a personal psychological history that makes her behavior a
bit more comprehensible.

Dr. C’s early memories of her father were of a happy, active man
who took her on great adventures. When she was eight years old, he was
diagnosed with diabetes. The girl knew that her doctors told him that
he needed to eat right and take medicine if he wanted to be healthy, and
she tried as hard as she could to help him with that. Although he initially
struggled hard and was good about following his diet and taking his
regular injections of insulin, his condition did not improve. He was no
longer as available to her when he was sickly and he eventually became
quite withdrawn; he began to feel hopeless about his condition and
was no longer so careful about his eating and medication adherence.
She was always encouraging of her father to eat better and to take his
medication, but he would become resistant and then angry with her,
rebuffing her efforts to help him. This future doctor watched her father’s
health deteriorate despite her best efforts and eventually he died when
she was 13 years old. Her admiration of his doctors inspired her to
become a physician herself, and she imagined herself saving people
from terrible illnesses. When her father died, she missed him terribly.
But her experiences with her father were also traumatic for her in a way
she never appreciated. From her childlike perspective, her father died
because he refused to do what the doctors had told him to do. She loved
her father tremendously and did not realize that she was also angry with
him; in her unconscious mind, he was responsible for his own death,
which had left her feeling alone and abandoned. Her experiences with
her father led her to work hard as a doctor to keep people healthy, but
her unacknowledged feelings of anger toward her father prevented her
from empathizing with her patients who were suffering. Whenever a patient reminded her of this aspect of her father, the doctor-patient
relationship became an adversarial one and she forgot that they were
both actually on the same side. It was not until she realized that her
punitive behavior with her patients was her unconscious way of still
trying to keep her father alive that she was able to return to a stance of
empathy and compassion for her patients who were suffering.

While it is important for doctors to see the whole patient, they
must also be able to see their whole selves. They must understand that
they bring medical knowledge and technical skills to their work with
patients, but they also bring their own subjectivity: the desire to heal,
anxiety about failure to do so, reactions to loss, responses to patient’s
narratives, counter-transferential reactions to difficult patients. They
react as people, though their training may discourage them from giving
voice to this. Psychoanalyst and general practitioner, Michael Balint,
recognized that doctors become deeply affected by what goes on with
their patients [48] With his wife, Enid, he developed what have come to
be known as “Balint groups” [49], psychodynamically-oriented groups
in which physicians have the opportunity to share their reactions to
their most emotionally challenging cases. The groups provide an
emotionally safe opportunity for reflection and an opportunity to
process the difficult experiences doctors encounter in medical practice
[50,51].

Holding Environment

Freud’s ideas have been researched and refined [52,53], and
extended to patient populations other than the neurotic, repressed
adults treated by Freud. Winnicott was both a pediatrician and a
psychoanalyst who was interested in the mother-child relationship. He
contributed a key relational concept called the “holding environment”
[54]. He observed that an appropriately responsive mother provides a
secure and accepting, non-punitive physical and psychological space
for the baby or young child to safely feel and express his or her feelings,
anxieties and infantile passions. He used this model of the motherbaby
relationship as analog to the therapist-patient relationship in
psychotherapy and psychoanalysis. In accepting and being attentive to
the patient’s inner experience, the analyst “holds” the patient, creating
a safe environment in which they can both get to know his or her true
self. Likewise, the concept of the holding environment can be readily
applied to the relationship between medical patient and medical
clinician; the doctor, by attending non-judgmentally to the subjective
experience and anxieties of the patient in the context of illness, can
provide an environment of safety, soothing and psychological holding.
The medical milieu can also be seen as providing a potential holding
environment for staff as well as patients. Psychologists, through group
interventions, “hold” the staff in some high stress settings such as
Emergency Departments and Intensive Care Units to help them with
their experiences of loss and vicarious trauma [55,56]. Even a wellrun
office with attentive staff can serve as a holding environment for
anxious patients waiting to be seen.

In sum, modern psychoanalysis has a great deal to offer to modern
medicine. Delivery of care can be greatly enhanced by attending to the
overlooked internal world of all who participate in the medical system.
The relationship between physician and patient can be viewed usefully
through an intersubjective lens, which sees the patient, not as passive
recipient of care, but as a partner in a dyadic interaction in which each
member has an impact on the other. The greater the clarity a clinician
has regarding the subjective experience of the patient, the better the
clinician will be able to empathize with and influence the patient toward
healthful behavior. Finally, the entire medical system has the potential to provide a complex holding environment, in which the anxious
vulnerabilities brought about through confrontations with sickness and
death might be contained and assuaged through careful attention to the
subjective states of both the patients and clinicians.

Conclusion

When serious illness is involved, all participants in the medical
relationship - patients and clinicians - confront anxiety and psychological
trauma on a regular basis. Modern medicine saves lives, but as it
does so, it can subject people to profoundly disruptive psychological
experiences that can result in anxiety, depression, fear, grief, anger and
other difficult emotional states. Traditional medicine treated the entire
person within the context of a family and a familiar doctor-patient
relationship, whereas modern medicine emphasizes individual body
parts, technology, fast action and cost-effectiveness over interpersonal
connection, subjective experience or reflection. There is now reduced
personal contact between the person of the patient and the person of
the doctor. Psychoanalysts have demonstrated that at times of stress,
people seek proximity to attachment figures, those familiar providers
of care who are a source of comfort. Individual patterns of attachment
get played out in medical settings when a person encounters the stresses
of illness. Traditional psychoanalytic concepts such as symbolization,
unconscious communication, transference and counter-transference,
as well as those from contemporary psychoanalytic theory, such as
inter-subjectivity, mentalization, attachment security and holding
environment, can be utilized to both understand and improve the
psychological dimension of modern medicine.

The present paper proposes that a contemporary, relational
psychoanalytic framework be utilized to organize thinking about the
problems inherent to the practice of modern medicine. Psychoanalytic
research shows that being emotionally attended to, psychologically
recognized and understood - being treated as a subject, not merely an
object - has calming and healing properties that can be helpful when
people are contending with the anxieties and potential trauma of serious
illness. The capacity to mentalize - to understand the psychological
dimension of oneself and one’s patients - can go a long way toward
improving the relationship between doctor and patient and toward
addressing the common complaint of patients that their doctor does
not know them. The present paper proposes a conceptual reframing of
the interpersonal interactions within the system of modern medicine.
The following are offered as concrete ways in which psychoanalytic
ideas can positively influence the practice of modern medicine. All
of these involve attention to the subjectivity of the participants in the
medical relationship.

1. Take steps to ensure that the doctor/doctor’s office is experienced
as consistent and available, i.e. establish a secure base for the
patient.

2. Medical clinicians attend to the subjective experience of the
illness and the medical treatments. i.e. engage in mentalization.

3. Medical clinicians attend to the subjective impact of the illness
and treatments on family members.

5. Integrate a psychoanalytically/psychodynamically-informed mental health clinician into the medical practice in order to
provide consultation or direct intervention when problems arise.

6. Call on mental health clinicians for consultation.

7. Provide a holding environment in the form of patientcentered
care in which specialists form an integrated team by
communicating with one another and with the patient. This helps
to reduce the patient’s sense of fragmentation due to involvement
of multiple specialists.

8. Provide a comfortable holding environment for patients who
are waiting to be seen, e.g. short waiting time to see the doctor,
attentive support staff.

9. Provide a holding environment for all medical clinicians,
particularly those who deal closely with loss and trauma. This
may involve psychologist-led groups.

10. Be attentive to one’s own emotional reactions to patients and to
what they might mean for the patient or for oneself [48].

Skomorowsky Anne (2012) The antisocial patient in the hospital. In: O’Reilly-Landry M (Ed.), A Psychodynamic Understanding of Modern Medicine: Placing the person at the center of care. Radcliffe Publishing, London, 108-116.